For many years, mental health professionals were guided by the Diagnostic and Statistical Manual to differentiate bereavement from depression. In other words, if someone is grieving the loss of a loved one, don’t assign a primary diagnosis of depression. However, it looks like this is about to change.
The American Psychiatric Association is in the process of revising the DSM and is proposing a change to the bereavement exclusion. The proposed change says that after two weeks…no, this is not a typo…after two weeks if the individual is still grieving and the grieving behavior fulfills the requirements for a depressive disorder, then give them the diagnosis for depression
I listened to an interview this morning with two of the psychiatrists involved in making these changes. The first one said that we expect “modest” grief for a couple of weeks after the death of a loved one, but then this stage of grief abates for most people. The second psychiatrist used the analogy of a broken leg, comparing it to the depressed state related to grief. The comparison seemed obtuse.
I don’t know anyone who, after grieving the death of a loved one for two weeks, wouldn’t be still in the thick of it emotionally—intermittent crying, despondent, poor appetite, etc. Yes, they may be depressed but do they have a disorder? I don’t think so.
The proposed changes to the bereavement exclusion defy common sense and do not seem to be proposed for the benefit of those deeply grieving. Frankly, I believe it is being done to create another justification for medicating people. It’s that simple—and appalling.
In the shock of grief, a sedative (old-fashioned term) is useful to help a bereaved person sleep. This is compassionate if the individual is so hysterical and too emotionally exhausted to sleep. It’s not something to do over an extended period of time, however.
Mostly, those who are heavily grieving need care: a hug, a hand held; the company of a close friend or relative who will listen when needed or simply be there in quiet support; privacy; chicken soup; an offer to help with errands or small tasks—we all know the routine. Treating grief primarily as a medical problem is wrong. Sure, grief can evolve into prolonged depression where mental health help is indicated, but not at the two week mark. What kind of message does that give to the bereaved? It tells them that a normal, difficult process they are going through is pathological. That message isn’t helpful. It’s foolish and borders on being cruel.
This proposed change reminds me of another revision of the Diagnostic and Statistical Manual many years ago when the term Adjustment Reactions was changed to Adjustment Disorders. Adjustment Reactions addressed the normal struggles we all go through when we have a major stressor or transition in our lives. Adjusting to it is difficult and we need some guidance and support to navigate confusing and painful times. With the change, what was normal became a disorder—another example of pathologizing ordinary human struggles that gives people the message that something is wrong with them.
The medicalization of human behavior has become a confused mess. Our ordinary and complex lives are being funneled into the land of disorders, which further removes us from common sense approaches to helping those in need.